Stress is often considered by patients and clinicians alike as an important factor in the onset and maintenance of widespread musculoskeletal pain, the relationship is more complex than appears on initial consideration. The types of event that lead to stress need description, and the role of traumatic events are particularly important because of the shared association with post-traumatic stress disorder.
The substantial overlap with psychiatric disorders and the role of stress in their etiology must be assessed in patients. The lack of specificity of the symptoms of the different disorders used to describe widespread musculoskeletal pain may be explained by their shared etiology, including neural sensitization and alterations of the hypothalamic-pituitary-adrenal (HPA) axis due to stress. Fear avoidance is a central stress-related perceptual characteristic and behavioural dimension in these disorders. Treatment depends on thorough assessment, including psychiatric diagnosis, avoiding simplistic attributions and implementing evidence-based treatments that are well documented1.
The effects of chronic stress can be seen even in infants. When compared to a group of healthy term infants, it was found that hospitalized infants had significantly higher hair cortisol levels (a stress marker). A subgroup analysis of the term infants in the neonatal intensive care unit showed a statistically significant association between total number of ventilator days and hair cortisol levels. For every extra day on the ventilator, hair cortisol levels increased significantly indicating that hair cortisol is influenced by days on the ventilator 2.
Emotional distress is a predictor for low back disability in persons with earlier low back pain, but not in persons without. To prevent low back disability, emotional distress should be considered and treated in persons with low back pain3. In a study on computer users aged 45 or older, perceived work demands influence neck/shoulder musculoskeletal symptoms through their effect on felt stress4.
Distressing sensations, thoughts, and emotional experiences exert influence on the daily functioning of those who suffer with chronic pain. In a study examining the role of mindfulness in relation to the pain, emotional, physical, and social functioning of individuals with chronic pain, it was found that mindfulness was unrelated to age, gender, education, or chronicity of pain. However, mindfulness accounted for significant variance in measures of depression, pain-related anxiety; physical, psychosocial, and “other” disability. In each instance greater mindfulness was associated with better functioning5.
1. McFarlane AC. Stress-related musculoskeletal pain. Best Practice & Research in Clinical Rheumatology. 21(3):549-65, 2007 Jun.
2. Yamada J. Stevens B. de Silva N. Gibbins S. Beyene J. Taddio A. Newman C. Koren G. Hair cortisol as a potential biologic marker of chronic stress in hospitalized neonates. Neonatology. 92(1):42-9, 2007.
3. Brage S. Sandanger I. Nygard JF. Emotional distress as a predictor for low back disability: a prospective 12-year population-based study. Spine. 32(2):269-74, 2007 Jan 15.
4. Larsman P. Sandsjo L. Klipstein A. Vollenbroek-Hutten M. Christensen H. Perceived work demands, felt stress, and musculoskeletal neck/shoulder symptoms among elderly female computer users. The NEW study.European Journal of Applied Physiology. 96(2):127-35, 2006 Jan.
5. McCracken LM. Gauntlett-Gilbert J. Vowles KE. The role of mindfulness in a contextual cognitive-behavioral analysis of chronic pain-related suffering and disability. Pain. 131(1-2):63-9, 2007 Sep.